Recognizing the Signs of Schizophrenia

Schizophrenia is a mental health disorder with varying and often difficult-to-manage symptoms, requiring accurate identification and treatment. Individuals with schizophrenia experience psychotic symptoms that interfere with daily functioning, but effective treatment can help manage these symptoms.

Recognizing Schizophrenia Symptoms

Schizophrenia is a diagnosable mental health disorder with a specific set of symptoms. These symptoms are listed in the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5). This manual is used to diagnose schizophrenia and other mental health conditions.

The symptoms of schizophrenia, according to diagnostic criteria, are broken down into positive and negative symptoms. Positive symptoms include changes in behavior and thought patterns, such as hallucinations or delusions. Negative symptoms are characterized by withdrawal and isolation from the world and daily functions. Both sets of symptoms often greatly affect a person’s life and make living with schizophrenia difficult if left untreated. ^[1]

Positive Symptoms

• Experiencing false beliefs called delusions.
• Experiencing hallucinations.
• Disorganized speech that is incoherent or hard to follow.
• Bizarre or catatonic behavior.

Negative Symptoms

• Social withdrawal.
• Lack of motivation.

Diagnostic Criteria for Schizophrenia

To be diagnosed with schizophrenia, a person must show at least two of the symptoms noted above. At least one of these symptoms must be delusions, hallucinations, or disorganized speech.^[1] These are considered the active symptoms of schizophrenia. ^[2] A person who experiences just negative symptoms, such as catatonic behavior would not meet the criteria for schizophrenia. A person must show at least one positive symptom for more than a month to be diagnosed.

Other diagnostic criteria for schizophrenia include: ^[1]

• Active symptoms must occur for at least a month and be present for a significant portion of time.
• A person must show signs of a mental disturbance for at least 6 months.
• The symptoms must cause difficulty with functioning in important life areas, such as work or relationships.

How Does a Schizophrenia Diagnosis Work?

A person cannot self-diagnose schizophrenia. Instead, a mental health professional, such as a clinical social worker, psychologist, psychiatrist, or clinical counselor, can make a diagnosis. These professionals can make a schizophrenia diagnosis if a person meets the criteria, as outlined in the DSM-5.^[1]

The process of diagnosis begins with a schizophrenia assessment. The clinician will gather a complete history of the patient, including their family background and history of symptoms. The diagnostic process will include psychological evaluation, in which the clinician uses validated tests for schizophrenia to determine if symptoms for diagnosis are present. It’s also important for patients to undergo medical evaluation to rule out alternative explanations for psychiatric symptoms. ^[1]

Psychological Tests for Schizophrenia

As part of the assessment process for schizophrenia, a mental health clinician uses psychological tests to confirm that a person meets diagnostic criteria. These psychological tests have been evaluated to ensure accuracy. Such tests include a series of questions that a patient answers, in collaboration with a mental health professional, to determine if the person meets schizophrenia diagnostic criteria.

Some tests commonly used in schizophrenia screening and diagnosis include:

• The Positive and Negative Syndrome Scale (PANSS): The PANSS test is one of the primary assessments available for evaluating schizophrenia symptoms. This test measures positive symptoms, such as hallucinations and delusions, as well as negative symptoms like social withdrawal and apathy. In addition to positive and negative symptoms, the PANSS includes an assessment of general psychopathology. The PANSS includes 30 items, and it contains items related to delusions, hallucinations, suspiciousness, abnormal thought content, social withdrawal, blunted emotions, and social withdrawal. Items related to general psychopathology include tension, hostility, preoccupation, and attention problems, among other items. ^[3]
• Brief Psychiatric Rating Scale (BPRS): The BPRS is also used to assess schizophrenia symptoms. The original version of this assessment contained 16 items, but a 24-item version has since been created. This version includes questions such as those related to bizarre behavior and self-neglect. The BPRS also includes items related to hallucinations, unusual thought content, and social withdrawal, making it appropriate for assessing schizophrenia symptoms. ^[4]
• Rorschach Inkblot Test: The Rorschach Inkblot Test is a projective assessment that evaluates personality features using images called inkblots. A person is shown an inkblot that forms a random pattern and is asked to describe what they see. Their responses are then interpreted by a psychologist to identify schizophrenic traits. While widely recognized, the Rorschach test is heavily derided by professionals and is rarely used in diagnostic settings. ^[5]

Medical Tests for Schizophrenia

While psychological tests are the primary tools used to assess schizophrenia symptoms, medical tests are also utilized. Ideally, a person who is suspected of having schizophrenia will undergo medical testing to rule out alternative causes of schizophrenia symptoms. For instance, symptoms that appear similar to schizophrenia may be attributable to a condition like multiple sclerosis or a metabolic disorder. ^[1]

To rule out alternative diagnoses, the following types of medical tests may be completed:

• Blood Tests: Blood tests can detect alternative explanations, such as infections, thyroid conditions, or electrolyte imbalances, which may mimic schizophrenia symptoms. ^[1]
• Brain imaging: Brain imaging can rule out dementia or other neurological conditions that may explain symptoms. ^[1]
• Electroencephalogram (EEG): An EEG can identify a seizure disorder that better explains symptoms. ^[1]

What Are the Challenges of Diagnosing Schizophrenia?

While there are useful diagnostic tools for schizophrenia, the reality is that diagnosing this disorder can be challenging. First, diagnosis requires a comprehensive evaluation, which includes medical tests to rule out alternative explanations for symptoms. Often, this means a person should seek evaluation from both mental health professionals and medical professionals, such as a physician. ^[1] This process can be time-consuming and costly.

Second, there is no one singular presentation of schizophrenia, so two patients who both have the disorder may present differently. This can make the process of diagnosis complex. A person must show two of five schizophrenia symptoms to be diagnosed but there are multiple different symptom combinations. For instance, one person with schizophrenia may experience delusions and social withdrawal, while another may show hallucinations, delusions, bizarre behavior, and unusual speech. ^[1]

Finally, a clinician must consider cultural factors when making a schizophrenia diagnosis. A person may appear to present with delusions, but if the beliefs linked to the delusions are culturally appropriate or typical, a schizophrenia diagnosis may not apply. A clinician must use discretion to determine whether beliefs are truly indicative of psychiatric disturbance, or simply part of a culturally-sanctioned practice. ^[1]

Differential Diagnosis

Another complicating factor in schizophrenia diagnosis is the fact that other psychiatric disorders may appear similar to schizophrenia. So, a clinician must also rule out alternative psychiatric disorders. The mental health disorders below may appear similar to schizophrenia, and a clinician must consider them when making a diagnosis: ^[1]

• Substance use disorders: The effects of some substances can produce symptoms, like hallucinations or bizarre behavior, that appear similar to schizophrenia symptoms. Clinicians must evaluate patients for substance use disorder history and consider whether the effects of a substance can explain symptoms.
• Depression or bipolar disorder: Some individuals experience psychotic features during episodes of depression or bipolar disorder. A clinician must assess whether a patient meets the criteria for depression or bipolar disorder, rather than schizophrenia.
• Schizoaffective disorder: Schizoaffective disorder is diagnosed in people who experience symptoms of schizophrenia, alongside mood disorder symptoms. If symptoms of depression or mania are also present, schizoaffective disorder is the more accurate diagnosis.
• Delusional disorder: Delusions are a symptom of schizophrenia, but some patients experience delusions in the absence of other psychiatric symptoms. If delusions are the only symptom present, a patient is diagnosed with delusional disorder rather than schizophrenia.
• Schizotypal personality disorder: As a personality disorder, schizotypal personality disorder involves enduring traits. Individuals with this personality disorder show eccentric behavior, lack of close friendships, paranoid behavior, and odd patterns of thought and speech. The odd behaviors in schizotypal personality disorder may appear similar to schizophrenia. However, an individual with schizotypal personality disorder will not experience the severe hallucinations and delusions seen in schizophrenia. ^[6]

What Happens After a Schizophrenia Diagnosis?

After a clinician makes a schizophrenia diagnosis, they will recommend a treatment plan to manage symptoms. Schizophrenia is typically treated with a combination of pharmacological and psychological approaches, or using a combination of medication and therapy. ^[1]

Medications used to treat schizophrenia include: ^[1][7][8]

• First-generation antipsychotics: including trifluoperazine, perphenazine, prochlorperazine, acetophenazine, triflupromazine, and haloperidol.
• Second-generation antipsychotics: including olanzapine, quetiapine, clozapine, and risperidone.
• Mood stabilizers like lithium.

Some patients may take injectable antipsychotic medications to help them stick with treatment. If you’re taking a daily dose of antipsychotic medication, it’s essential to continue taking it, even after symptoms improve. If a medication is working, it should be part of your ongoing treatment regimen. ^[1]

Sometimes, schizophrenia is considered treatment-resistant. This means symptoms don’t improve with medication. If this happens, a doctor may try a higher dose or a different medication. Staying in contact with your doctor is important, so they can monitor your response to medication and make changes if needed.^[1]

In addition to pharmacological treatment, many people with schizophrenia participate in psychological treatments. This can include group therapy during which patients receive education about schizophrenia. Other psychological treatments include supportive therapy, family therapy, and cognitive behavioral therapy for psychosis. Individuals with schizophrenia may also participate in social skills training and community treatment services to support their rehabilitation. ^[1]

Once a person is diagnosed with schizophrenia, they must continue to take medications and remain in treatment to manage symptoms. If treatment is stopped, schizophrenia symptoms are likely to return. However, with ongoing treatment, it is possible to live with schizophrenia and function in daily life. ^[1]